Provider Demographics
NPI:1720065444
Name:WALLING, JEFFREY BLAKE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BLAKE
Last Name:WALLING
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8451 PINEVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-9105
Mailing Address - Country:US
Mailing Address - Phone:762-416-4059
Mailing Address - Fax:
Practice Address - Street 1:8451 PINEVIEW LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-9105
Practice Address - Country:US
Practice Address - Phone:763-416-4059
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112889-7183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist